Laughing, Crying, and Worrying About the N.H.S.

The success of “This is Going to Hurt,” a darkly funny book by a former National Health Service doctor, has coincided with a period of deep anxiety about the future of Britain’s health system.Photograph by Antonio Olmos / eyevine / Redux

In early 2016, Adam Kay, a former obstetrician, began receiving e-mails from the General Medical Council, which oversees Britain’s medical profession. Kay, who was in his mid-thirties, had stopped practicing medicine five years earlier, but he had put off the decision to formally give up his license. The G.M.C. warned Kay that he needed to renew his qualifications, which prompted him to finally remove his name from the medical register. As Kay cleared out his old files, he came across a clinical diary that he had kept during his six years working for the National Health Service. The diary was supposed to be a portfolio of “reflective practice” to help him improve as a doctor, but Kay, who had previously performed as a standup comedian and was working as a TV writer, had filled his diary with swearing, accounts of missed Christmases, and off-color anecdotes. The entries had become longer as his career progressed. It had been his way of coping.

Monday, 9 October 2006:

Today crossed the line from everyday patient idiocy to me checking around the room for hidden cameras. After a lengthy discussion with a patient’s husband about how absolutely no condoms fit him, I establish he’s pulling them right down over his balls.

Kay had been a “junior doctor” in the N.H.S. Like many things to do with the health service, the term is not readily comprehensible. It does not mean a junior doctor. Instead, it covers every level of hospital doctor except for the most senior, who are known as “consultants.” Around fifty thousand junior doctors work for the N.H.S., which provides free health care to a population of sixty-five million people. Most spend around a decade in the role, delivering babies, diagnosing cancer, and carrying out all but the most demanding operations. In 2016, as Kay was putting an official end to his medical career, the junior doctors went on strike over pay and working conditions for the first time in forty years. Eighty per cent described themselves as experiencing “excessive stress,” and a quarter believed that their work had a serious impact on their mental health. It has long been common for junior doctors to work hundred-hour weeks on a regime of punishing, seemingly randomly devised shift patterns. “In retrospect, my diaries were a form of therapy,” Kay told me recently. “That was my looking for shards of light among the dark.”

The last major strike was in April, 2016. After that, Britain’s Health Secretary at the time, a polished Conservative politician named Jeremy Hunt, imposed a new contract on the junior doctors, which most believed to be unfair. Hunt also accused the doctors of putting patients at risk during the strikes—a calumny, many felt, given that overstretched hospitals and exhausted staff were already endangering people’s lives. Kay wanted to tell the doctors’ side of the story. “I wasn’t sure I had ever read a book that said what the whole life of a doctor looks like,” he said. But he wanted people to laugh as well. He decided to read excerpts from his diary at Edinburgh’s Fringe Festival that summer. Before taking the material to the festival, he invited some friends to hear it at a small theatre in North London. The friends liked the show but sensed an absence. They didn’t realize that Kay had left out the final entry in his diary and the reason he had stopped being a doctor.

In December, 2010, Kay was overseeing an emergency Caesarean. He had delivered more than fifteen hundred babies by this point and was the most senior doctor on the ward, just below a consultant. A less experienced doctor was carrying out the operation when she asked Kay to take over because the mother was bleeding heavily. The patient had an undiagnosed placenta previa—a condition in which the placenta attaches to the womb near or over the cervix—and she should never have been allowed to go into labor in the first place. The Caesarean was a catastrophe. The baby died, and the only way that Kay could stop the bleeding was to hold the uterus together with his hands. The mother lost twelve litres of blood and was admitted to intensive care.

My consultant talks to the husband. I start to write up my operation notes but instead cry for an hour.

There was no question of negligence. Everyone was perfectly nice. Kay was expected to carry on as before, but he found that he couldn’t. He drifted for a few months, doubting himself, and then quit. He didn’t tell any of his friends or family about the operation. (Kay’s father and two of his siblings are doctors.) The first time Kay’s husband understood why he had left medicine was when he watched Kay read the diary entry near the end of his show at the Edinburgh festival, in August, 2016. “I was in trouble about that,” he said. “Because that is one of the things you are not supposed to keep secret.”

Kay’s parents found out only last September, when his diary was published as a book, “This Is Going To Hurt.” Kay tidied up some of the entries and swapped personal details to protect his patients’ privacy, but every episode is drawn from truth. The book has spent the last year at the top of the U.K. best-seller lists and has sold more than seven hundred thousand copies. (Little, Brown will publish the book in the U.S., next year.) It is being made into an eight-part drama for the BBC. Whenever Kay appears in public now, people line up to talk to him about their experiences of Britain’s hospitals, which are under great and obvious strain, while doctors message him privately on Facebook, confiding in him their own traumas and fatigue.

Kay misses being a doctor and feels guilty about leaving the profession. It comforts him that by sharing his diary he is letting people know what his former colleagues are going through—albeit through the misdirection of humor. “It’s a confidence trick,” Kay told me. “It is a lowercase-‘P’ political book. But if I had called it ‘Adam’s Harrowing Polemic About the State of the N.H.S.,’ you know, it wouldn’t have done as well.”

The success of “This is Going to Hurt” has coincided with a period of deep anxiety about the future of Britain’s health service. The N.H.S. was founded, seventy years ago, in 1948, as part of the new society that emerged after the Second World War. Since then, its fortunes have served as a kind of E.C.G. for the country’s political and economic health. Under Tony Blair’s New Labour government, the N.H.S. received huge increases in funding—between 2000 and 2010, spending rose by ninety-two per cent—and was subjected to an array of reforms. There were missteps but waiting times fell, and health outcomes improved. Under the austerity program of Conservative-led governments since 2010, however, the N.H.S. has suffered. Spending has never actually fallen (this year, it will surpass a hundred and twenty-five billion pounds for England alone), but the budget has not kept up with the inexorable needs of an aging population, the rise of chronic conditions such as obesity and diabetes, and the cost of increasingly personalized care. Since 2014, the N.H.S. has been attempting to reform itself for the twenty-first century and save money at the same time—a project that appears impossible.

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Last winter, faced with the predictable, seasonal surge in demand for treatment in the nation’s hospitals and emergency rooms, the N.H.S. in England more or less fell over. In January, twenty hospitals declared “black alerts”—discharging patients whose lives were not in danger and cancelling tens of thousands of operations. The writer James Meek chronicled the disaster in a twenty-one-thousand-word essay for the London Review of Books: “Between them, the hospitals in Worcester and neighbouring Redditch had to divert emergency patients elsewhere at least 65 times. At Derriford Hospital in Plymouth, staff were stretched so thin they were unable to take breaks. Memos between managers at Southmead Hospital in Bristol in early January, leaked to the local press, warned that beds were ‘104 per cent full.’ ” The winter passed, but the sense of an ongoing crisis has not. Doctors, nurses, and administrative staff are all leaving the N.H.S. and not being replaced. Last week, with winter approaching again, workforce figures revealed vacancies for eleven thousand five hundred doctors and forty-two thousand nurses across the system. Nine per cent of N.H.S. posts are currently unfilled. “Widespread and growing nursing shortages now risk becoming a national emergency,” the King’s Fund, the nation’s leading health think tank, reported.

“It is much worse now than it was when my book ended,” Kay told me. Nonetheless, his diary conveys the sense of working in a monumental, maddening machine. The N.H.S. is by far Britain’s largest employer, with one and a half million staff members. Employees are bound by outdated hierarchies and quixotic management targets. Its I.T. failures are legion: Kay’s e-mail address, given to him on his first day at work, was atom.kay@nhs.net. (“It’s good to know that no matter what happens today, nobody could accuse me of being the most incompetent person in the hospital.”) Every year, on the same day, junior doctors in the N.H.S. move to a new hospital, an administrative nightmare known as Black Wednesday for the accompanying rise in death rates. Doctors are buzzed throughout their shifts by beepers that give no information except an extension number to call, making it difficult to prioritize requests. At night, a single junior doctor, fresh out of medical school, is often given responsibility for every patient in the hospital who is not in surgery or in the emergency room. “The fucking lot of them,” Kay writes. “You’re up on the wards, sailing the ship alone. A ship that’s enormous, and on fire, and that no one has really taught you how to sail.”

It struck me that almost every reference in his book to the N.H.S. as a system—the bureaucracy, the politicians, the low pay, the chronic underfunding, the brutal professional culture, the ridiculous hours—was decidedly negative. Yet nearly eighty per cent of the population thinks the N.H.S. should continue in its current form, and two-thirds would support tax increases to pay for it. When I met Kay last week, in London, I asked him why we, the British public, and he, a traumatized former doctor, like the system so much. “It is difficult to justify the N.H.S. sometimes,” Kay conceded. To explain Britain’s health system in the international editions of his book, he compares it to a classic car that has been in the same family for generations. “It takes leaded petrol, we indicate by sticking our hand out the window and start the engine by cranking a handle on the front—but it all still works,” he writes. “You’ll never convince us to change. It’s not a matter of logic, it’s not even a matter of nostalgia—it’s love.” More or less, the only thing that keeps the N.H.S. going is the fact that people insist on believing in it. “We have proved the N.H.S. can be wonderful if it is funded appropriately,” Kay said. “We have also proved that if you take away the funding people work themselves to the ground to keep it going as best they can.”

That evening, he was performing his show at the Duchess Theatre, not far from Covent Garden. In person, Kay is mild and amusing. Onstage, his bedside manner is slightly demonic. He wore a Joy Division T-shirt and read from his battered clinical diary, a large, blue, plastic binder, with something approaching glee. The audience was full of doctors, and I realized how transgressive it felt—and what an immense relief it was—to hear a medical professional take the piss out of the N.H.S. It was like the moment when someone finally has the nerve to tease a sainted, but deeply annoying, member of the family. Kay told the story of a boy who had managed to de-glove his penis (don’t ask) by sliding down a lamppost while celebrating his exam results. He interspersed his reading with silly songs about emphysema and yellow fever. Nobody was prepared for the final, heartbreaking journal entry. Kay finished the show on the verge of tears, as he always does, and then gave a speech reminding people to protect and treasure the health service. “Now I’m going to take a bow,” he said, “and I am going to share it with all the doctors and all the nurses out there.” Kay allowed a beat. “Even the shit ones.” And everybody laughed.

A lock of Walt Whitman’s hair, Jack Kerouac’s boots, and Virginia Woolf’s cane are just a few of the items of literary paraphernalia available at the New York Public Library's Berg Collection—if you have an appointment.